A woman needed a radical hysterectomy after a family doctor failed to both give correct advice and follow up test results.
Health and Disability Commissioner Anthony Hill also faulted an unnamed medical centre over the case in 2012.
The case involved a woman with a history of cervical abnormalities who also, unusually, had two cervixes.
In 2012, her unnamed GP took two smear samples from both but only got one result, which was clear.
The medical centre later received another but it was not expected and was misfiled.
Despite the woman's history and other worrying symptoms, she was expected to wait six months for a colposcopy.
When she went for one privately, she found she had cervical cancer, which was now in remission.
Mr Hill said her GP should have discussed specialist care with her earlier, should have followed up all test results and should have advocated for her patient.